Should Suicide by Self Starvation be Prevented?
I received a very nice letter from a reader of Secondhand Smoke that I thought I would share with y'all to see what you think: She wrote in part: "I am curious to know what your stance on self-starvation is, since someone recently accused you of being a "hypocrite" (I really disagree with that judgement) for believing that self-starvation is not suicide. Unfortunately, I'm having a little trouble navigating your blog to find articles that reflect your opinion. What would you recommend I read to have your opinion best represented in this matter?"
This is the relevant part of my response: "I don't recall ever discussing self-starvation. Unless the person means that I think people have a right to refuse tube feeding if they become incapacitated. My position is I don't support that morally, but I would not try to prevent it legally, assuming the person has put it in writing. In that case, the person would die of natural processes, not self starvation. If an elderly person stops eating as the body shuts down due to old age and the dying process, that too is natural and not self starvation, when he or she refuses to eat. If that person does not want a feeding tube, I would respect that desire since a feeding tube is surgery, and they are not refusing to eat due to mental illness.
"Self-starvation as a form of suicide would be different. It used to be done in Roman times. This is something of a first impression for me, but if a person is depressed and wishes to self starve to death, otherwise having the capacity to eat and drink, I think that that person's life should be saved just like we would if he or she were going to jump off a bridge. And I don't think that would require a feeding tube or that kind of surgery. It would require a legal finding that the person is beyond a reasonable doubt a threat to themselves. Under such conditions, the state can hospitalize the suicidal person for treatment. I see no reason why that would not also apply to self starvation suicide...
"I guess your friend thinks I am a hypocrite because I am not a vitalist, that is, I don't think that everything has to be done on every occasion, no matter how much suffering it causes, to keep people alive. I don't see it as hypocrisy, though. People have a right to personal autonomy, that is, the right to refuse unwanted medical interventions. For example, Pope JP II did not have everything done that could be done to extend his life, and I think he was a very ethical man." (And I should have added, that JP II certainly didn't commit suicide.)
The floor is open to anyone who wishes to comment. Thanks.
posted by Wesley J. Smith @ 9:01 PM
17 Comments
17 Comments:
I had to ask you why you had a moral problem with a person refusing a feeding tube, but would not pursue it legally.
If what is done is immoral, should not there be a law to prevent that immoral act? If not, then why make abortion illegal just because it is not moral to do so. I need some clarification as to why you find something to not be moral, but would not pursue upholding that morality legally.
Thanks,
Phil
I had to ask you why you had a moral problem with a person refusing a feeding tube, but would not pursue it legally.
If what is done is immoral, should not there be a law to prevent that immoral act? If not, then why make abortion illegal just because it is not moral to do so. I need some clarification as to why you find something to not be moral, but would not pursue upholding that morality legally.
And isn't upholding ones automomy problematic when it is an immoral act? Juveniles are quite possibliy being given the right to kill themselves because they are depressed. What difference is there between a person who is depressed and wants to kill themselves and a person who is in a good frame of mind and wants to keep themselves from eating with a feeding tube? The result seems to be the same and does not society has some kind of obligation to address these situations in such a manner that affirms life, rather than affirms a persons so called right to kill themselves because they are either depressed or imcapcitated. Not wanting to be fed with a feeding tube seems to be a little crazy as well.
Thanks for you impute,
Phil
Well, sheerly practically speaking, I think it probably _would_ require a feeding tube if the person were otherwise refusing to eat. You can't force a person to chew and swallow. So if it were determined that the depressed person envisaged was a threat to himself and should be stopped from starving himself, then I think in the end (in the hospital) they would have to use a feeding tube or an IV, and perhaps both. Is this not usually what is done when prisoners go on hunger strikes and the state finally intervenes to stop them from actually harming themselves?
I have no problem with this, myself. If someone says I'm in favor of "force feeding," I'll say that yes, I am in favor of this in some circumstances--as when the person is otherwise going to damage or kill himself by starvation or dehydration.
But this would mean that there would be circumstances where a person refused to eat normally but did _not_ have a right to refuse a feeding tube, when the feeding tube was the only way to get food and fluids into him.
I think that if you apply this to all people who are not dying from some other cause (and dying within a pretty short time, too, not in five years or something), it's going to apply fairly widely. _I_ have no problem with that, but perhaps you (WJS) will feel uncomfortable with it.
On one thread I saw a fellow mention his aunt who was told she would have to go into a nursing home. The impression given was that she wasn't dying but just was going to need more care than her family could give at home. According to the poster, she just stopped eating or drinking the minute she was told about the nursing home, and so she died of dehydration after a couple of weeks and avoided the nursing home. I'd say this (if the facts are really just like this) would be a case for force feeding.
To Phil Magnan:
In no way do I presume to speak for Mr. Smith, but I thought about your question and think I may have an answer. In a case where death is imminent and nothing can be done to prevent it, if a person has provided legal documentation asking that her feeding tube be removed to simply hasten the inevitable, while it may disturbe a person on a moral level, in this case legislating against the action would really not accomplish anything worthwhile. Properly cared for, a person who is that severely ill might not suffer physically as much as she would by waiting to die from the disease. I personally feel each case should be looked at separately for assessment before that kind of treatment is offered.
I don't really feel that the above senario fits into the category of offering juvenils the "right" to kill themselves. A person who is depressed may intentionally be overlooking possible solutions or better pain management care. A person in his right mind may refuse feeding if his body, due to the dying process, simply cannot accept feeding. I refer here to a case of the granddaughter of my boss. Last September, at the age of 9, she died of brain cancer. Although she was lucid and aware toward the end, because her body functions had shut down so completely, she was unable to eat, and all a feeding tube would have done was make her more uncomfortable, and it would not have prolonged her life. The cancer killed her before she could starve to death, but she did not eat the last two days of her life.
I really say that each case should be looked at individually before an assessment can be made.
You made some very interesting points, Mr. Magnan, and thank you for your well-reasoned arguments.
phil magnan: Wouldn't it be terribly arrogant of me to seek to outlaw any conduct that I believe is morally wrong?
I don't know if this is phil's position, but people of my particular moral view are often accused by those who don't like us of trying to "impose" our views on society. Then, when we don't, we are accused of hypocricy for not seeking to impose our views. As my dear old Dad used to say, I can't win for losing.
I think that it makes a large difference whether the person is going to die of dehydration before he would die of the underlying condition. If someone is going to die of cancer in six months, becomes weak or unconscious, and has signed a document refusing tube feeding, then he is going to die *of* the dehydration in 1 to 2 weeks. I think there's a major ethical problem here. The fact that he _has_ cancer, even terminal cancer, and that this has caused his weakened state where he can't just interact and eat normally, doesn't mean that he's dying _of_ the cancer when he ceases to receive fluids and his kidneys shut down from that after 2 weeks. To call this merely "hastening the inevitable" is, in my view, to use euphemisms. The proximate cause of death is dehydration.
I do think this can be a kind of suicide. And because I think suicide can be legislated against, I think death by refusing nutrition and hydration can be legislated against. Of _course_ this doesn't mean that everything that is immoral can be legislated against.
It would protect a lot of people though even if we just prevented the dehydration deaths of _non-dying_ people. There are plenty of people who have had strokes but are not therefore dying who are deemed (rightly or wrongly) to be "unable to eat by mouth." In this case, if they've signed a document that they don't want a feeding tube, they are dehydrated to death. I think this is especially wrong and a form of killing, all the more so as the person was non-dying. It's not at all clear to me that the signing of the document takes care of the problem. Not only do many people sign such documents in confusion, but even if they did fully understand, this would simply make it a case of suicide for a non-dying person.
You are exactly right, Lydia. Here's another example. There are occasions when a person is suffering to the point that the only way to alleviate it is sedation. The "death with dignity" crowd often calls this "terminal sedation." But it is better called "palliative sedation" since the sedation doesn't kill, nor does any withdrawal of sustenance. It is the disease.
To Lydia McGrew:
I agree with your reasoning; a person who has had a stroke shouldn't be denied the right to life, especially as we gain new insights into how the brain works and learn to "rewire" it, so to speak, so that someone who has had a stroke can live life fully. The case of the cancer patient is a little bit harder, though. The case of my manager's granddaughter is one way to look at it: she died of cranial hemoraging, not dehydration or starvation, even though she was so sick she couldn't eat for two days. When the body starts shutting down, the ability to process food at all can go out the window. If a person is believd to have six months to live, but the digestive organs start to fail, and if food can no longer be processed at all, how does one handle the situation? IV drips are a good way around the situation, on the one hand. On the other hand, how badly destroyed is the body by the disease? The problem with legislation is that it's a blanket solution, but it ignores the individual. This is my big fear with the "right to die" crowd. "We have the right to die" is a blanket statement that covers people who don't want to be covered. I think all law should err on the side of human life, and have just enough give to allow doctors and families to assess each individual case on its own merits.
It's so hard to try to decide what the best road to take is because each person is totally unique and will have different experiences. All I know is that end-of-life care is not what it should be.
To Mr. Smith:
Terminal Sedation, as it is known, is terribly ignored. Just goes to show you that the subject is undervalued because I never even thought of it in my response to Lydia. It certainly isn't something you hear about often in the media, and not many websites talking about end-of-life treatments bring it up.
Mr. Fine and everyone: Please feel free to call me Wesley. Thanks.
Wesley, my impression is that the phrase "terminal sedation" is used specifically for very high doses, doses that do significantly hasten and in some cases even cause death. Is this not true? That's what Nancy Vallko is talking about when she writes against "terminal sedation," I know. I'd suspect that's what the Death w/ Dignity folks mean. My impression--again, correct me if I'm wrong--is that the law is much more easy-going now on significant overdoses of morphine than it used to be, even when it's pretty clear that such a high dose of morphine has caused the death through suppressing breathing. Some pro-lifers seem to think this loosening up of the law is a good thing, as it allows doctors to alleviate pain without fear of prosecution. I tend to think it's not such a good thing, as I've heard quite a few anecdotal cases where the person was undoubtedly killed knowingly by the high dose of morphine.
T.E. Fine: But no one dies in 2 days either of dehydration or of starvation. Two days without food is nuthin' in the world of end-of-life care. That is, it's completely obvious (as you say) that the young lady died of her underlying condition if that's all the longer she was without food. So it doesn't seem to me that cases like that go to support the legitimacy of ceasing food and fluids for those who are "terminally ill" generally, _much less_ merely incapacitated.
If a person's digestion is really shutting down en toto, I don't think he'd have a projected six months to live. Wesley will know more about this than I, but I don't think IV glucose drips can keep you alive for six months all by itself.
Where I think the problem comes in is where we see absolutely classic cases of death by dehydration--the time period is just right (1 to 2 weeks after cessation of food and fluids), the pattern of the death is right (e.g. including kidney failure some time after fluids are stopped), and so forth, but we're told that the person died of "natural causes" because he did already have some other serious condition, even though apparently that condition wasn't killing him all that rapidly. All my suspicions are aroused by these cases.
Wesley, I do think you may have a tough choice to make: There are going to be cases where a person really is sick and/or old, isn't mentally ill, isn't dying imminently (e.g. in a few days to a week), stops eating by mouth (e.g. because of weakness, sleeping many hours a day, or even because of a desire to die and get it over with), but has said that he wouldn't want a feeding tube. Is it really such a bad idea--morally or legally--to give him a feeding tube anyway in such a case? After all, it's usually argued that the person can be given drugs so as not to feel the distress of dying of dehydration. In that case, what's so bad about giving him a little Atavin so he won't feel anxiety over having an NG tube? And objectively speaking, he'll probably be more physically comfortable receiving the fluids. I'm not sure patient autonomy is the most important thing, here.
To Wesley:
I got into the habit of using Mr. or Ms. when I got told off for being disrespectful to the owner of another blog by calling her by her name. Thank you for letting me know it was cool.
To Lydia:
I see your point. This is such a tricky matter. By the way, I apologize for shoving my ignorance into everyone's face. Unfortunately, my father recently had to undergo chemo and surgery to get rid of cancer, and all of these concerns came home to roost the moment we found out he was sick. He's doing fine right now, but the ethical questions are driving me crazy. I (being a daddy's girl) don't want him to die at all, but should something happen in the future that requires us to make a choice like this, what am I supposed to do if he chooses to, say, let himself die of dehydration?
One wants to do what is ethically and morally right, but one does not want to cause unnecessary pain and suffering, either. I feel like the subject is constantly stuck at a stale mate. All of your arguments are correct, Lydia, but somehow I can't help but think that there is something wrong with keeping a terminal patient alive for a limited amount of time. Then I think about my father and I really, really don't want to justify dehydrating him to death if it came to it. Every moment he is alive I can be with him and love him and memorize him.
I find your attitude persuasive, Lydia, but may I ask you, how would you feel in a similar situation? I regret that I do not have the sophistication to phrase that any better, because it sounds accusing, but that isn't my intent. I'm actually curious because I'm trying to see every side of the issue. By the way, thank you for chatting with me on this issue.
Well, my mom has multiple myeloma, so no doubt this will come up in my life eventually, though she's free of symptoms for the time being.
Legally, it's a moot question. The Cruzan decision set it in stone that a person can refuse artificial nutrition and hydration. So to some extent a lot of this doesn't have practical relevance.
Cancer patients do often come to not want food. If I were in your place, T.E., I'd probably talk as persuasively as I could to my dad early on about the importance of hydration, to at least prevent him from making a living will requesting that he _not_ be given tube feeding. Then you could play it by ear when the issue arose. For example, you've mentioned IV hydration. That can help even with a cancer patient who doesn't want to eat. And ice chips and spoon feeding are very often possible in small amounts even when the person doesn't want much.
I think a very important thing is that people not feel that there's something wicked and unnatural about "tubes." I've had some trouble with my mom with this, because she's much into having everything "natural." (Natural foods, for example.) So initially, about ten years ago, she thought of tube feeding in this irrational "icky" way as "unnatural." But that doesn't really make sense. It's just another way of getting food and fluids. One thing to try to get across is that food and fluids aren't _treatment_, no matter how they are administered.
I think it's important to realize in a situation like yours, too, that if the person is dying of cancer, he's going to die when the time comes. The phrase "keeping him alive," I think, can cause confusion. Just giving food and fluids to the extent that the person can process them isn't some sort of major, heroic intervention that is going to prevent death indefinitely. If someone is really _imminently_ dying--say, in less than a week--then that's going to happen. If he has an NG tube, for example, or an IV, to get some fluids, he's still going to die quite quickly if he's on the way out. And if that _isn't_ true, then we really _are_ talking about death by dehydration, which is pretty gruesome in itself.
For what it's worth, Wesley was mentioning John Paul II. Some "right to die" folk have made a song and dance about his staying in his apartment at the end and not having all sorts of heroic interventions. That's true. What they often neglect to mention is that he had a feeding tube at the end (an NG tube, as I read it, which doesn't require surgery). But he died a relatively peaceful, natural death. So those are compatible.
Thank you, Lydia. What I want is for my dad to have the fullest possible life, and not to have his life needlessly ended. Every moment I have with him I treasure, and there is always something beautiful to share. I like your recommendations. Thankfully, Dad is now cancer-free (between radiation, chemo, and surgery, all of the cancer was removed before it could spread), and I don't have to worry about the issue for some time yet, but since he's starting to suffer from depression (all the medications he has to take are playing merry cob with his mental state, which everyone expected, of course, and we're taking steps against that), I don't want him to contemplate something that he would actually regret.
I think the principle of double effect applies to Terminal Sedation - the purpose is to allievate pain but a side-effect might be to hasten death - we don't always know what a lethal dose is for a particular patient.
JP2 had a non-surgical feeding tube.
They were also using them at Guantanamo, which brings up whether hunger strikes and such are moral. I think it was Bobby Sands and some others who starved themselves to death under Thatcher.
Am I the only one who finds it ironic that Terri Schiavo was starved to death when we really didn't know, but we forcefed prisoners at Gitmo at the same time so we could continue to inflict suffering upon them?
And let me propose another case. Lets say I'm worry that I will be incarcerated so I take a slow poison so that I will die in two weeks if I don't take an antidote. I'm captured, so I say release me or I will die - and refuse to tell them how to prevent my death, only noting I can do so myself. In effect I hold myself hostage.
Thomas, lethal doses of morphine are not so mysterious as all that. Of course, individual patients will vary, but the fact remains: Doses that previously would not be given because it was known that they were dangerous, plausibly lethal, are now given without any repercussions at all. There seems to be far less care in the use of morphine than there used to be. Double effect simply won't work if the dose is too high. It won't work morally for morphine anymore than for any drug that has a lethal dose. The drugs prescribed in Oregon for assisted suicie are also medications that have legitimate uses, but that doesn't mean that the doctor who prescribes the suicidal dose under the suicide law is doing something moral under double effect.
Phil
I can understand that you may have good intentions, but I look and look and almost all that I see is related to coercing, persuading otherwise or just plain taking the whole thing out of the hands, perhaps even the ken, of the one at the centre of all this.
I live in a country in which a dignified death, under the control of a sane and deeply suffering individual, is not overtly practiced but where many a compassionate doctor existswho will not allow it all to progress to a grotesque, drawn-out finale. As a retired AIDS worker I have held the hands of many as the light went out. Some begged to be killed up till near the end. I suffer myself from an illness which causes me great pain and will eventually kill me. I live alone (no family) and in fear, though a spiritual peace I could never have thought possible under these circumstances has come to me through praying for the peace of others and by meditating and becoming more awake to what is happening, and will happen, to me. This has carried me beyond the time I was told I have left. But I am now the only remaining member of the 15-strong clinic of which I was a member. My body doesn't work properly any more, and being medically educated, I am under no illusions about the future. Thank the skies for countries which allow a quiet, dignified injection at a date and time chosen by the sufferer. Please lose all these ideas about controlling the wishes of others (I'd bet my bottom dollar this is an American site; but then, we're all allowed to be wrong sometime, eh?), and if you care so much about Life, try to take on a little about Suffering. You may wish to start with some of the fellow lifeforms for whom we conceited and chauvinistic humans, with all our fine, advanced moral and ethical constructs have made this good earth a living hell. Auschwitz taught us nothing.
With love and peace,
Clear
(and hey folks, let's not drag 'god' into all this, huh?)
Post a Comment
Subscribe to Post Comments [Atom]
<< Home